Healthcare Provider Details

I. General information

NPI: 1790080653
Provider Name (Legal Business Name): JACEY A. ROBERTS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACEY A. BENNIS PA-C

II. Dates (important events)

Enumeration Date: 01/24/2011
Last Update Date: 12/23/2021
Certification Date: 12/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1046 TULIP TER
ROCKINGHAM VA
22801-5324
US

IV. Provider business mailing address

1412 FAIRMOUNT AVE
PHILADELPHIA PA
19130-2908
US

V. Phone/Fax

Practice location:
  • Phone: 540-421-0779
  • Fax: 540-438-0023
Mailing address:
  • Phone: 215-599-4851
  • Fax: 215-232-4093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110005554
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA054722
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: